Advances in the treatment of patients with life-threatening illnesses have resulted in a growing population of "chronically critically ill" (CCI) patients who have recovered from an initial critical illness, but go on to require prolonged periods of time on mechanical ventilators in the hospital. The CCI are at high risk for mortality, morbidity, and readmission. Families of the CCI confront enormous challenges as they face decisions about goals of care, as well as benefits and burdens. Identification and frequent re-evaluation of goals of care have been recognized as essential yet often neglected components of supportive communication and decision making with families of the critically ill. We know very little, however, about specific ways to assist families in this process and how communication affects patient outcomes. Reaching consensus about goals of care in CCI may present particular challenges because CCI is often not recognized, prognosis of CCI is not well accepted, and ICUs are poorly equipped for consideration of goals other than survival. A key component of intensive care for these patients is intensive communication. Lack of understanding and evidence needed to provide specific directions to clinicians is a significant barrier to improving end of life care. Thus, there is a need to develop and test interventions that can more effectively and consistently promote shared communication and decision making with families of CCI patients. The specific aims of this proposal are to examine the effect of implementing an intensive communication system (ICS) on CCI patient and family outcomes and resource use in ICUs of varying specialties. The research questions are: (a) what is the effect of implementation of an ICS for families of CCI patients on ICU resource use? (b) What is the effect of implementation of an ICS for families of CCI patients on family depression, satisfaction with communication, and satisfaction with care? (c) What is the effect of implementation of an ICS on patient outcomes (mortality, readmission)? (d) What is the association between effectiveness of the intervention and family demographics (age, relationship to patient. ethnicity); (e) What are the key process characteristics of communication in ICS?